Abstract
OBJECTIVE: To determine the frequency and determinants of provider nonrecognition of patients’ desires for specialist referral.
DESIGN: Prospective study.
SETTING: Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan.
PARTICIPANTS: Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits.
MEASUREMENTS AND MAIN RESULTS: Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients’ referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P<.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P<.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered “not indicated” by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred.
CONCLUSIONS: These PCPs frequently failed to explicitly recognize patients’ referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire.
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References
Franks P, Clancy CM, Nutting PA. Gatekeeping revisited-protecting patients from overtreatment. N Engl J Med. 1992;327:424–9.
Forrest CB, Starfield B. The effect of first-contact with primary care clinicians on ambulatory health expenditures. J Fam Pract. 1996;43:40–8.
Martin DP, Diehr P, Price KF, Richardson WC. Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health. 1989;79:1628–32.
Glenn JK, Lawler FK, Hoerl MS. Physician referrals in a competitive environment: an estimate of the economic impact of a referral. JAMA. 1987;258:1920–3.
Greenfield S, Nelson E, Zubkoff M. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267:1624–30.
Donohoe MT. Comparing generalist and specialty care: discrepancies, deficiencies and excesses. Arch Intern Med. 1998;158:1596–608.
Webb S, Lloyd M. Prescribing and referral in general practice: a study of patients’ expectations and doctors’ actions. Br J Gen Pract. 1994;44:165–9.
Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9:75–81.
Hornberger J, Thom D, MaCurdy T. Effects of a self-administered pre-visit questionnaire to enhance awarencess of patients’ concerns in primary care. J Gen Intern Med. 1997;12:597–606.
Kravitz RL, Callahan EJ, Azari R, Antonius D, Lewis CE. Assessing patients’ expectations in ambulatory medical practice. J Gen Intern Med. 1997;12:67–72.
Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in patients presenting with physical complaints. Arch Intern Med. 1997;157:1482–8.
Tabenkin H, Revital G, Brammli S, Shvartzman P. Views of direct access to specialists. JAMA. 1998;279:1943–8.
Rosenthal TC, Riemenschneider TA, Feather J. Preserving the patient referral process in the managed care environment. Am J Med. 1996;100:338–43.
Borowsky SJ. What do we really need to know about consultation and referral? J Gen Intern Med. 1998;13:497–8.
Kravitz RL, Callahan EJ, Paternitic D, Antonius D, Dunham M, Lewis CE. Prevalence and sources of patients’ unmet expectations for care. Ann Intern Med. 1996;125:730–7.
Kerr EA, Hays RD, Lee ML, Siu AL. Does dissatisfaction with access to specialists affect the desire to leave a health plan? J Gen Intern Med. 1996;11:77. Abstract.
Gallagher TH, Lo B, Chesney M, Christensen K. How do physicians respond to patients’ requests for costly, unindicated services? J Gen Intern Med. 1997;12:663–8.
Feldman DS, Novack DH, Gracely E. Effects of managed care on physician-patient relationships, quality of care and the ethical practice of medicine. Arch Intern Med. 1998;158:1626–32.
McLeod P, Tamblyn R, Gayton D, et al. Use of standardized patients to assess between physician variation in resource utilization. JAMA. 1997;278:1164–8.
Calman NS, Hyman RB, Hecht W. Variability in consultation rates and practitioner level of diagnostic certainty. J Fam Pract. 1992;35:31–8.
Franks P, Clancy CM. Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance. J Fam Pract. 1997;45:47–53.
Albertson G, Lin CT, Swaney R, Anderson S, Anderson RJ. Patient-provider interactions in the subspecialty referral process in a gatekeeper model academic managed care plan. J Gen Intern Med. 1998;13(suppl):103. Abstract.
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This work was funded by University Hospital Board of Directors, Denver, Colo.
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Albertson, G.A., Lin, C.T., Kutner, J. et al. Recognition of patient referral desires in an academic managed care plan. J GEN INTERN MED 15, 242–247 (2000). https://doi.org/10.1111/j.1525-1497.2000.02208.x
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DOI: https://doi.org/10.1111/j.1525-1497.2000.02208.x